Clinical Section

Correction of Posterior Crossbites:

Diagnosis and Treatment
Robert E. Binder, DMD
Dr. Binder is professor of orthodontics and interim chair, New Jersey Dental School, and professor of Oral Biology, Graduate School of
Biomedical Sciences, University of Medicine and Dentistry of New Jersey, Newark, NJ.
Correspond with Dr. Binder at binderre@umdnj.edu

Abstract
The correction of posterior crossbites is more complex than it appears. To develop an
appropriate treatment plan, it is first necessary to determine if: (1) there is a functional
jaw shift on closing; (2) the crossbite is unilateral or bilateral; (3) it is dental, skeletal, or
a combination of both; and (4) it is related only to the maxilla or both jaws. Once the
problem’s apparent cause has been defined, it is then necessary to select the appropriate
modality of treatment, which, in the maxilla, is: (1) usually a removable acrylic-based
appliance with 1 or more transverse screws; or (2) a fixed Hyrax-type or Hass-type ap-
pliance. In the mandible, if dental expansion is required, the appliances most frequently
used are the lip bumper or a removable acrylic-based appliance with a single screw lin-
gual to the incisors. Once the appliance has been placed, it must be determined when
clinical section

adequate expansion has been achieved and how best to retain it. (Pediatr Dent.
2004;26:266-272)
KEYWORDS: ORTHODONTICS, CROSSBITE, MALOCCLUSION, APPLIANCES
Received January 16, 2002 Revision Acccepted April 7, 2004

M
any patients have a noticeable crossbite of the The secondary effect of palatal expansion is the direct
buccal segments when their occlusion is in maxi- result of increasing the transverse dimension. This results
mum intercuspation. Less frequently recognized, in a total arch circumference increase that is approximately
there might be a narrowing of the maxilla or palate without 75% of the increase in width.8
an apparent crossbite. The incidence of posterior crossbite The indications for palatal expansion include:
varies from a low of 7.3% in the Hispanic population to a 1. relief of a posterior crossbite with a skeletal compo-
high of 9.6% among African Americans, with whites in be- nent; and
tween at 9.1%.1,2 When these problems are treated, it is 2. gaining a small amount of space to relieve anterior
essential that the proper diagnosis be established and an ap- crowding (usually less than 4 mm).
propriate treatment plan be developed.
Diagnosis
Rationale
History
Posterior crossbites that result from a functional shift of During the dental history collection, it must be determined if
the mandible should be treated as soon as clinically feasible the patient had a digit-sucking problem, and if so, its frequency,
after they are found. Such a shift in the posture of the man- intensity, duration, and persistence. In addition to the fre-
dible from its first contact in a centric posture to maximum quently observed proclination of the maxillary incisors and the
intercuspation may result in a number of sequella in both creation of an anterior open bite, strong and persistent suck-
hard and soft tissues. The changes that may occur include: ing habits can cause a narrowing of the maxillary dental arch
1. compensatory changes in the temporomandibular ar- in the transverse dimension as well as compensatory lingual tip-
ticulation; ping of the mandibular buccal segments. Such narrowing may
2. the development of skeletal asymmetries; or may not create an apparent dental crossbite.1,2
3. modifications of soft tissue growth; and
4. attrition of the primary and secondary teeth.3-7

266 Binder Correction of posterior crossbites Pediatric Dentistry – 26:3, 2004

 Diagnostic records
To develop a definitive treatment plan, it is essential that
the appropriate diagnostic aids be collected in addition to
a clinical examination. At a minimum, it is necessary to pre-
pare adequate study models and radiographs that depict
A both the teeth present in the oral cavity and those devel-
oping in the alveolar processes. For the latter, a panoramic
radiograph is ideal. A posterior-anterior cephalometric ra-
diograph is useful in:
1. measuring the transverse dimensions of the maxilla
and mandible to calculate if a transverse discrepancy
exists; and
B 2. assessing the position of the dental midlines in rela-
tion to their respective skeletal midlines.6
Figure 1. Bilateral crossbite with functional shift.
Figure 1A. Occlusion with maximum intercuspation (unilateral An occlusal radiograph is used to assess the mid-palatal
crossbite, midlines do not align, mandibular shift to left). suture patency. In most cases, the suture can be separated
Figure 1B. Occlusion in centric relation (bilateral crossbite, midlines with a fixed appliance in females up to age 16, and in males
do align).
up to age 18, depending on when they entered puberty
and/or stopped growing. For children with primary denti-
Clinical examination tion and early mixed dentition, sutural separation is best
A functional examination of the mandible’s closing path- achieved with removable appliances. Premature use of fixed
way from maximum opening to first contact and then final, rapid palatal expansion appliances has been known to cre-
maximum intercuspation must be performed to determine ate an increase in nasal width.3
if a lateral or anterior-posterior mandible shift occurs fol- Radiographs also indicate formation stages of the per-
lowing first contact. The patient is asked to open his/her manent teeth’s developing roots and the resorption of their

clinical section
mouth as wide as possible and keep it open for a short pe- primary precursors. The root structure amounts remain-
riod of time to confuse or eliminate proprioceptive ing on primary molars will determine if these teeth are
memory. Possible mandible shifting is then evaluated by capable of supporting a fixed-expansion appliance. Fixed
having the patient close the mandible slowly from maxi- appliances placed on premolars whose roots are only par-
mum opening until the first contact of centric occlusion tially formed may cause dilaceration or resorption.
while the tongue is curled back toward the soft palate. The Radiographs must also be checked for congenitally miss-
amount and direction of any mandible shifting between ing teeth. Expansion appliances of all types increase arch
first contact and maximum intercuspation should be noted. circumference, as they increase arch width at an approxi-
Functional shifts may mask the real problem, which is fre- mately 0.75 mm increase in circumference for every 1 mm
quently more severe than the apparent one, as in buccal of increased arch width. For patients diagnosed with con-
crossbites. Or it may make a problem appear worse than it genitally absent teeth, expansion may create too much space
really is, as in pseudo Class III malocclusions. and, thus, be an inappropriate mode of treatment.8
In many instances, what appears to be a unilateral Assessment of properly trimmed orthodontic study casts
crossbite when the occlusion is evaluated in maximum in- can provide a wealth of information that is difficult or even
terdigitation is, in reality, a bilateral crossbite with a impossible to obtain from even the most thorough clinical
functional lateral jaw shift (Figures 1A, 1B) as the teeth shift examination. The curves of Wilson and the degree of pos-
from centric relation to centric occlusion. A key sign in terior teeth tipping to the buccal or lingual side can be
cases with this type of functional shift is the deviation of determined by viewing the models from the rear. With the
the mandibular dental midline, relative to the maxillary models articulated by hand, the intercuspation of the lin-
dental and skeletal midlines, toward the side of the crossbite gual cusps and vertical overbite of the incisors can be
when the teeth are in maximum intercuspation. Treatment visualized from the rear of the models, which is impossible
of a simple dental alveolar unilateral crossbite may require to do on the patient. The viewer can also assess compensa-
using fixed or removable appliances to move the teeth. In tory dental-alveolar changes that frequently occur in skeletal
bilateral skeletal crossbites, the treatment of choice may be crossbite situations.
separation of the midpalatal suture. The index of treatment In cases of true maxillary transverse insufficiency, maxil-
need categorizes both posterior crossbite types as severe and lary dentition is frequently tipped to the buccal side and the
require treatment.2,9 mandibular buccal dentition is tipped to the lingual side in
A preliminary assessment of the palate width may be an apparent effort to compensate for the mismatching of the
made by placing the thumb into the depths of the palatal skeletal apical bases (Figure 2A). If the teeth were uprighted
vault. If the thumb does not fit comfortably, it is an indi- with conventional orthodontic appliances, the dental
cation the palate might be too narrow. crossbite would match the skeletal crossbite (Figure 2B).

Pediatric Dentistry – 26:3, 2004 Correction of posterior crossbites Binder 267

 9. What appliance(s) should be considered?
10. Will the patient tolerate the suggested appliances?

Methods of treatment
Once a problem list has been defined, a treatment plan can
be established and the appropriate mechanotherapy selected
to achieve the desired results. There are some differences
in the techniques used to increase the transverse dimen-
sion due to the midpalatal suture in the maxilla and its other
sutural connections to the facial skeleton.
Appliances common to both arches
The type of device that is most frequently used in either
A arch is the acrylic-based removable appliance with 1 or
more expansion screws.10-12 Typically, the mandibular ap-
pliance is constructed with a single expansion screw located
at the midline lingual to the central incisors (Figures 3A,
3B). The maxillary type may have 1 or 2 screws, which are
usually located transversely over the median raphe. When
a single screw is utilized in a maxillary appliance, it is
anteroposteriorly located between the premolars or primary
molars (Figure 3D). When 2 screws are employed, they are
positioned in the middle of the canine and second premo-
lar (Figure 3C). In a basic appliance, retention is achieved
via clasps placed on the premolars, primary molars, or mo-
clinical section

lars. The most commonly employed clasps—which engage

the proximal buccal undercuts—are Adams (Figure 3A) or
ball clasps (Figures 3A, 3E), with circumferential clasps
used less frequently (Figure 3B, 3C).
B Changes in the transverse dimension and, thus, the
Figure 2. Compensatory changes in dentoalveloar processes to
crossbite, are achieved by turning the screw(s) between the
compensate for skeletal transverse discrepancies. appliance’s 2 acrylic halves in the same direction once or
Figure 2A. Tipping of maxillary teeth to the buccal and mandibular twice each week. Most commercial laboratories embed di-
teeth to the lingual to compensate for mismatched skeletal bases.
Figure 2B. The effect of uprighting teeth creates a dental crossbite rectional arrows into sides of the acrylic surfaces to guide
relation that matches the apical base. the patient as to the direction the screw key is to be turned.
Each screw’s turn between the guide posts opens the ap-
pliance 0.25 mm (Figures 3A, 3B). As the screw is turned,
This “molding” of the teeth and dental alveolar processes is the appliance’s acrylic body applies pressure to the teeth’s
created by the balance of buccinator muscle forces on the lingual surfaces and alveolar processes to achieve move-
outside of the oral cavity and the tongue on the inside. ment. Contact between the teeth and appliance is only
along the junction of the acrylic and the gingival margins.
Treatment planning This essentially creates a narrow band of contact and, thus,
With the aid of the diagnostic materials’ history and evalu- a tipping moment (Figure 3G).
ation, a list of problems that need to be resolved is Adding a bite plane to the appliance, with acrylic cover-
developed and treatment plan is established. To do this, ing the teeth’s entire lingual and occlusal surfaces and also
the following questions need to be answered: extending for 2 to 3 mm onto the buccal surfaces, will help
1. Should treatment be initiated at this time or deferred to achieve a more bodily movement (Figure 3D, 3F). Addi-
to a later date? tional bite plan benefits include:
2. Is the crossbite unilateral or bilateral? 1. reduced intercuspation of the opposing teeth, thus en-
3. Is there a functional jaw shift? hancing movement;
4. Is the crossbite skeletal or dental? 2. increased appliance retention; and
5. If skeletal, which jaw is creating the problem? 3. aided elimination of persistent functional jaw shifts.
6. If dental, which teeth are tipped and in which jaws? Removable expansion appliances usually achieve their
7. Should the problems be corrected? effect by tipping the teeth and alveolar processes toward
8. Can the problem be corrected or masked by treat- the buccal. This is true for all mandibular applications
ment? because of the lack of a midline suture. In the maxilla,
true opening of the midpalatal suture with a removable

268 Binder Correction of posterior crossbites Pediatric Dentistry – 26:3, 2004

 A B

clinical section
C
D

E
Figure 3. Removable expansion appliance with screw(s).
Figure 3A. Drawing of a mandibular appliance with midline screw
lingual to the central incisors, Adams clasps on first molars and ball
clasps between the first and second primary molars.
Figure 3B. Mandibular appliance with midline screw lingual to the
central incisors, ball clasps mesial to the first primary molars, and
circumferential clasps engaging the undercut created by the buccal
tubes on the first molar bands. G
Figure 3C. Drawing of a maxillary appliance, with 2 screws located
on the midline approximately at the level of the canines and second Figure 3E. Maxillary appliance with midline screw, ball clasps
premolars. Circumferential clasps on the first molars and ball clasps between the first and second premolars, and a circumferential clasp
between the first and second primary molar. on the left first molar. The clasp on the right molar has been
Figure 3D. Maxillary appliance with ball clasps mesial and distal to removed.
the second primary molar, posterior occlusal tables, and a labial Figure 3F. Contact of appliance acrylic and the lingual surface of
bow. tooth (frontal view).
Figure 3G. Addition of a bite plane increases contact between the
acrylic and tooth (frontal view).

Pediatric Dentistry – 26:3, 2004 Correction of posterior crossbites Binder 269

 A B
Figure 4. Lip bumpers.
Figure 4A. Removable lip bumper—facial and occlusal view.
Figure 4B. Positioning of the lip bumper wire in relation to incisors expansion (side view).
Figure 4B-1. Ideal wire position to prevent incisor movement during expansion to control.
Figure 4B-2. Improper positioning of anterior wire may allow proclination of anterior teeth due to muscle forces.
Figure 4B-3. Positioning the labial wire below the level of gingival margin may result in distal tipping of the molars.

appliance is possible in patients with primary dentition bands: 2 on the first molars and 2 on the first premolars or
or early mixed dentition up to age 9 in females and 10 in first primary molars.16-18 In the Hass appliance, the screw
males. is embedded in a split-acrylic base, which also surrounds
Lip bumpers can also be used in both arches to achieve the heavy round wires soldered to and extended from the
dental alveolar expansion, but are most frequently used in 4 bands (Figures 5A, 5E). In the Hyrax appliance, the heavy
clinical section

the mandible.13-15 Lip bumpers are removable or fixed re- round wires are connected to the screw and are soldered
movable appliances that are fabricated from heavy round directly to the bands. In variations of these basic appliances,
wire (0.030 or 0.045 inch diameter). They are inserted into bands are placed on the second primary molars if:
round buccal tubes bonded or, more frequently, welded to 1. first primary molar is mobile;
bands fitted and cemented onto the first permanent mo- 2. first premolar has not erupted enough for bands to be
lars (Figure 4A). Lip bumpers can be used as removable properly fitted;
appliances, with the patient able to extract them at will, or To add rigidity to the appliance, heavy round wire buc-
they can be designed to be tied into place and only removed cal and/or lingual arms may be soldered to the bands
by the practitioner. (Figures 5A, 5C). Frequently, the lingual arms are extended
Lip bumper expansion is achieved by buccal tipping of to the second molars to assure that they are moved with
the posterior teeth. An expanded bumper wire will actively the other posterior teeth. The appliance is activated by plac-
move the molars to which they are attached while all other ing a “key” in the hole in the center threaded rod and
teeth are moved via a change in the balance of muscle moving it backward until it rests against the posterior sta-
forces. Proper positioning of the wire adjacent to the pos- bilizing bar. The key is removed while it is in this posterior
terior teeth reduces the force of the buccinator muscles, position to assure full movement.
resulting in a net increase of tongue pressure, thus creat- After the first day, the screw is usually turned twice each
ing movement. An improper relationship of the wire to the day, once in the morning and once in the evening, for a
anterior teeth can result in their proclination (Figure 4B- total of 0.5 mm per day. Some practitioners turn the screw
2) or the distal movement of the molars to which the bands 4 to 5 turns on the day of insertion or until a piece of den-
are cemented (Figure 4B-3). tal floss slips through the contact between the central
incisors without resistance, assuring that the suture has been
Maxillary appliances opened. Routinely, appliance expansion is continued un-
Fixed or fixed-removable appliances used in the maxilla fall til the buccal incline of the maxillary molars’ lingual cusps
into 2 basic categories: (1) those causing midpalatal suture are resting high toward the occlusal on the lingual inclines
separation; and (2) those that usually do not. The Hass- and of the buccal cusps of the mandibular molars. This over-
Hyrax-type rapid palatal expansion appliances fall into the expansion allows for:
first category and are employed to achieve crossbite correc- 1. physiologic rebound that will occur in the maxilla; and
tion via separation of the midpalatal suture (Figures 5A-D). 2. compensatory buccal uprighting of the mandibular
Quad helices and Porter or W arches nominally achieve ex- dentition that results from the changes in the muscle
pansion via dental-alveolar movement (Figures 5E, 5F). forces created by modification of the functional matrix.
Both the Hass and Hyrax appliances are constructed
with an expansion screw most frequently attached to 4

270 Binder Correction of posterior crossbites Pediatric Dentistry – 26:3, 2004

 A
B

clinical section
C D

E F
Figure 5. Maxillary expansion appliances.
Figure 5A. Hass-type rapid palatal expander with soldered buccal and
lingual supporting arms. 1. passing a piece of dead soft brass wire or a twisted liga-
Figure 5B. Hyrax appliance with soldered lingual supporting arm ture wire through the screw’s hole around one of the
extending to the mesial of canines. stabilizing posts; and
Figure 5C. Butterfly palatal expander.
Figure 5D. Super screw expander. 2. twisting the 2 ends into a pigtail, which is then tucked
Figure 5E. Quad helix appliance. under the appliance in the space between the screw
Figure 5F. W arch appliance.
and palate.
In Hass-type appliances, quick-cure acrylic can be used
Following the desired expansion, the appliance screw is to bridge the gap between the base components. To maxi-
“sealed” to prevent further turning. This is achieved by: mize stability of the expansion, the appliance is usually left

Pediatric Dentistry – 26:3, 2004 Correction of posterior crossbites Binder 271

 in place for a minimum of 3 to 4 months. It is then 5. O’Byrn B, Sadowsky C, Schneider B, BeGole E. An
replaced by a retainer.18 The older the patient is when the evaluation of mandibular asymmetry in adults with
expansion is performed and the longer the period of reten- unilateral posterior crossbite. Am J Orthod Dent
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In some cases, when greater expansion amounts in the 6. Cross D, McDonald JP. Effect of rapid maxillary ex-
anterior maxilla segment are desired, it is possible to em- pansion on skeletal, dental and nasal structure:
ploy a butterfly expansion device (Figure 5C). A relatively A postero-anterior cephalometric study. Eur J Orthod.
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screw,” which replaces the typical expansion screw with a 7. Hess K,Artun J, Joondeph D, Kennedy DB. Changes
threaded screw and nut device (Figure 5D). in condylar position and occlusion associated with
Quad helices and Porter or W arches are all constructed maxillary expansion for correction of functional uni-
with a W-shaped arch wire that crosses the palatal vault and lateral crossbite. Am J Orthod Dent Orthop.
is connected to the lingual surfaces of molar bands, usu- 1997;111:410-418.
ally on first molars. The W arch and the quad helix are fixed 8. Adkins MD, Nanda RS, Currier G. Arch perimeter
appliances, while the Porter arch is a fixed-removable ap- changes on rapid palatal expansion. Am J Orthod.
pliance.11,20-23 All 3 of these appliances may be activated 1990;97:194-199.
without removal from the oral cavity. This requires judi- 9. Broad PH, ShawWC. The development of an index
cious application of force from a 3-nosed pliers to modify for orthodontic treatment priority. Eur J Orthod.
the expansion built into the appliance prior to cementa- 1989;11:309-332.
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must be carefully made in a controlled manner to avoid after maxillary expansion in the mixed dentition. Am
undesired tooth movements. Although used less frequently J Orthod Dent Orthop. 1997;111:321-327.
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clinical section

is more precise. 1985;7:97-102.

12. Hicks E. Slow maxillary expansion: A clinical study
Conclusions of the skeletal versus dental response to low magni-
Fixed or removable maxillary and mandibular expansion tude force. Am J Orthod. 1978;73:121-141.
appliances—used either to correct transverse relationships 13. Ten Hoeve A. Palatal bar and lip bumper in nonextraction
or slightly increase arch circumference—should be an in- treatment. J Clin Orthod. 1985;73:272- 291.
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15 Osborn WS, Nanda RS, Currier GF. Mandibular arch
Acknowledgements perimeter changes with lip bumper treatment. Am J
The author wishes to thank the faculty, staff, and postgradu- Orthod. 1991;99:527-532.
ate students of the New Jersey Dental School for their 16. Hass AJ. Rapid expansion of maxillary deficiency by
assistance during the preparation of this manuscript, as well opening the mid-palatal suture. Angle Orthod.
as John Cummins for his help in preparing the photographs. 1965;65:200-217.
17. Hass AJ. Long term posttreatment evaluation of rapid
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